Nutmeg Liver

Congestive hepatopathy , also known as nutmeg liver and chronic passive congestion of the liver , is liver
dysfunction due to venous congestion, usually due to congestive heart failure . The gross pathological
appearance of a liver affected by chronic passive congestion is "speckled" like a grated nutmeg kernel; the
dark spots represent the dilated and congested hepatic venules and small hepatic veins. The paler areas
are unaffected surrounding liver tissue. When severe and longstanding, hepatic congestion can lead to
fibrosis ; if congestion is due to right heart failure, it is called cardiac cirrhosis . [1]
Signs and symptoms
Signs and symptoms depend largely upon the primary lesions giving rise to the condition. In addition to
the heart or lung symptoms, there will be a sense of fullness and tenderness in the right hypochondriac
region . Gastrointestinal catarrh is usually present, and vomiting of blood may occur. There is usually more
or less jaundice . Owing to portal obstruction, ascites occurs, followed later by general dropsy. The stools
are light or clay-colored, and the urine is colored by bile . On palpation, the liver is found enlarged and
tender, sometimes extending several inches below the costal margin of the ribs.
Pathophysiology
Increased pressure in the sublobular branches of the hepatic veins causes an engorgement of venous
blood, and is most frequently due to chronic cardiac lesions, especially those affecting the right heart, the
blood being dammed back in the inferior vena cava and hepatic veins. Central regions of the hepatic
lobules are red/brown and stand out against the noncongested, tan-coloured liver. Centrilobular necrosis
occurs.
Macroscopically, the liver has a pale and spotty appearance in affected areas, as stasis of the blood
causes pericentral hepatocytes (liver cells surrounding the central venule of the liver) to become
deoxygenated compared to the relatively better-oxygenated periportal hepatocytes adjacent to the hepatic
arterioles. This retardation of the blood also occurs in lung lesions, such as chronic interstitial pneumonia ,
pleural effusions, and intrathoracic tumors.
Treatment
Treatment is directed largely to removing the cause, or, where that is impossible, to modifying its effects.
Thus, therapy aimed at improving right heart function will also improve congestive hepatopathy. True
nutmeg liver is usually secondary to left-sided heart failure causing congestive right heart failure, so
treatment options are limited.